Advanced maternal age

Question 1

What are the benefits of AMA?

Answer 1

• Improved health and development in their children.
  
  • Improved cognitive ability of children.
  • Emotional and financial stability for children.

Question 2

What is the risk of spontaneous miscarriage with AMA and what is the pathophysiology for this?

Answer 2

Spontaneous miscarriage risk c.f. <30 11%:
>=35: 25%
>=40: 50%
>=45: 90%

Majority due to chromosomal anomalies; >50% are T21.

Oocytes have been suspended in Metaphase I: susceptible to oxidative stress and telomere damage.

Question 3

What is the age specific risk for Down syndrome?

Answer 3

Age 20: 1 in 1500
Age 30 : 1 in 900
Age 40: 1 in 150
Age 45: 1 in 28

Question 4

What is the age specific combined risk of T13, T18 and T21 on CVS?

Answer 4

○ C.f. 20 1:705
○ 35 1:180
○ 40 1:39
○ 45 1:14

Question 5

How much higher is the AMA risk of ectopic pregnancy and why?

Answer 5

3 x higher.

Due to accumulation of risk factors: multiple sexual partners, pelvic infection and tubal pathology.

Question 6

Why is the incidence of multiple pregnancies higher in AMA?

Answer 6

• Rising FSH levels resulting in more than one dominant follicle developing.
• Old ovum with fragile zona pellucida leads to two separate points of regrowth and splitting of the fertilized ovum.
• Increasing ART use

Question 7

What is the RR of HTN disorders in pregnancy?

Answer 7

RR 4

Question 8

What is the RR of placenta praevia?

Answer 8

RR 3

Question 9

What is the RR of PE?

Answer 9

RR 2.5

Question 10

What is the OR of GDM?

Answer 10

OR 3.7

Question 11

List the late pregnancy complications AMA women are at increased risk of

Answer 11

• HTN/PET
• IUGR
• PTB
• Stillbirth (0.9% >40; 1% >50 vs 0.5% <40)
• PE
• GDM
• Placenta praevia, accreta and abruption
• CS RR 4
• PPH

Question 12

What pre-conceptual counselling would you provide to a woman of AMA wanting to become pregnant?

Answer 12

• Warn of increased risks.
• Optimisation of medical conditions first: diabetes, HTN, obesity.
• Start pre-conception folic acid and iodine.

If using ART: only put one embryo back to minimise chances of multiple pregnancy.

Question 13

How would you manage an AMA woman differently in the antenatal period?

Answer 13

• Aneuploidy screening recommended: MSS-1 or NIPT (NIPT has higher sensitivity and specificity).
• Low dose aspirin from 12 weeks until 36 weeks.
• Warn about increased risk of GDM and PET and alter surveillance accordingly.
• GDM screening: consider first trimester screening.

Stillbirth risk reduction:

• Monitor FMs
• Sleep on sides
• Consider serial growth scans
• Smoking cessation

Delivery timing:

• IOL 39 weeks
• Consider elective CS if very AMA

Question 14

What postnatal advice would you give an AMA woman?

Answer 14

Interpregnancy interval of 12-18 months is associated with a reduction in maternal death